Billing for wound care seems easy based on its face value.

Debridement and E/M visits are performed; however, wound care is one of the most audited and misinterpreted areas of medical billing by both CMS and commercial payers.

Commercial payers and CMS understand that wound care services are frequently provided, repetitive, and vary greatly in nature. Thus, that is exactly why they are reviewed so thoroughly.

Most denial for wound care is based on documentation, coding and modifier usage that failed to provide adequate evidence to support the medical necessity of the services rendered as well as compliance to the payer’s rules and guidelines.

This guide will provide a comprehensive, step-by-step approach to assist you in achieving Wound Care Billing Compliance so your wound care claims do not experience denial, payment issues or audit.

Step #1: Document Everything, Every Single Time

Documentation of wound care is the backbone of the billing compliance of wound care services. Without adequate documentation of wound care, even the best CPT code or modifier will not be able to save the claim.

Commercial payers expect wound care documentation to provide a clear, concise clinical account of the patient’s condition from visit to visit.

Individual documentation is required for each wound. Each wound must have specific documentation, including where the wound is located, which side of the body it is on, and which part of the anatomy is affected.

Documentation of a “foot ulcer” is not sufficient. Commercial payers expect to see if the wound is located on the bottom of the foot (plantar), top of the foot (dorsal), inside of the foot (medial), outside of the foot (lateral), and/or if the wound affects the muscles, tendons, and bones.

The size of the wound is equally essential. Documentation of wound size should include the length, width, and depth, measured consistently at each visit. CMS expects to see evidence of measurable progress toward wound healing or a clinical justification when the wound fails to heal.

Sudden changes in measurements without documentation of the cause will raise red flags with payers.

Documentation of what type of tissue is inside the wound is also important. The wound documentation should clearly show if there is any dead tissue (necrotic tissue) that has died and is peeling off, or dead sloughing tissue which has died and is still attached to the wound bed. If the wound contains living tissue, it should be indicated whether this tissue is new (granulation tissue) or old (muscle, tendon, etc.).

Documentation of the type of tissue present within the wound will provide clear justification for the kind of debridement that was performed (selective or excisional).

Documentation of prior treatment of the wound is also expected. Payers want documentation of all prior therapies applied to the wound.

Payers want to see documentation that conservative measures were attempted before escalating to more aggressive wound care treatment. If the wound has failed to respond to treatment, payers wish to clear documentation of the reasons for continuing or escalating wound care.

Finally, documentation of wound care should clearly state the reasons the wound required the specific treatment provided on the particular date of service. If the documentation clearly indicates the reasons the wound required the specific treatment provided, then billing for wound care will be much simpler.

Step #2: Match ICD-10 Codes to CPT Codes

One of the most common errors in wound care billing is failing to properly match the ICD-10 code(s) assigned to the patient’s wound care condition to the CPT codes for the wound care procedures performed. In wound care, ICD-10 codes are not used solely to describe the wound. ICD-10 codes are used to justify the procedures performed.

For example, CPT codes for debridements require the assignment of ICD-10 codes that justify the presence of dead or dying tissue (devitalized/necrotic tissue). If the ICD-10 codes assigned to the patient’s wound care condition describe a superficial wound healing well and include healthy granulation tissue, the payer may deny the debridement as not medically necessary.

The location of the wound is also crucial. ICD-10 codes distinguish between skin damage, fat layer damage, muscle damage, and bone damage. The CPT code used for billing will need to be one that corresponds to the depth of damage documented with the ICD-10 codes.

A patient’s chronic condition(s) (i.e., diabetes, vascular disease, a pressure ulcer, etc.) may warrant wound care services. However, the chronic condition(s) will have to be coded and related to the specific wound(s) for treatment.

ICD-10 and CPT codes are a team. When the two sets of codes tell the same story, claims flow smoothly. When they do not, denials follow.

Step #3: Utilize Modifiers Properly, Using a Clear Decision-Making Process

Modifiers are common audit triggers in wound care billing, particularly modifiers 25 and 59. Modifiers are legitimate when used appropriately, but they have been grossly misused throughout the healthcare industry.

Modifier 25 is used when a separately identifiable significant e/m service is provided on the same day as wound care service performed. To be eligible for modifier 25 there must be documentation of a separate evaluation, clinical decision making and management of the patient’s wound care condition in addition to the performance of the wound care service.
To help determine if modifier 25 will apply, use this analogy: “would the e/m service have been justified if the wound care service had not been provided?” if the answer is no then modifier 25 is unlikely to apply.

Modifier 59 and the x-modifiers are used to indicate that distinct procedural services were performed. In wound care service modifier 59 and the x-modifiers are commonly used to demonstrate that distinct procedural services were performed on multiple sites or at seperate anatomical locations.

However, separate wounds alone are not a justification for the use of modifier 59. The documentation must demonstrate that the services were distinct, not overlapping, and not subject to bundling under CPT rules.

An internal decision tree can help reduce the risks associated with inappropriate modifier use. Ask yourself the following questions:

•   Were the services performed on different wounds?
•   Were the services performed at different anatomical sites?
•   Did the services require separate clinical decisions?

If the answer to any of the above questions is unclear, the modifier should not be used.

Proper modifier use will protect your practice’s revenue and reduce audit exposure.

Step #4: Track Denial Reasons and Look for Patterns

Denials are not random events. Denials for wound care billing follow patterns, though many practices view them as isolated events rather than indicators of underlying process problems.

Each wound care denial should be tracked with the reason for the denial, the payer involved, the CPT code assigned to the wound care procedure, the ICD-10 code(s) assigned to the patient’s wound care condition, and the modifier used. The more wound care denials there are, the more you will see trends in the way they are being denied.

You might be seeing the same types of reasons why your patients’ wounds were denied (e.g. lack of medical necessity; lack of adequate wound measurements documented; improper use of modifiers.

Patterns identified through denial tracking should be addressed upstream. If a payer repeatedly denies debridement due to insufficient documentation, the provider needs education from the payer on the documentation required for the payer to consider debridement medically necessary.

Denial tracking transforms billing into a feedback loop. Instead of reacting to each individual denial you could have taken steps before a patient’s wound was denied.

Industry research shows that practices which use structured systems to track their denials, collect a significant amount of additional revenue and are less likely to have the same type of denial occur again as compared to those practices that do not utilize these systems.

Step #5: Maintain Audit Ready Records at All Times

Audits of wound care claims are not a matter of if, but rather when. Maintaining audit-ready records is a requirement for ensuring wound care claims are audit-safe.

Maintaining audit-ready records requires documenting wound care, operative notes, wound measurements, photographs of the wound (if available), authorization for treatment of the wound, and documentation of billing for wound care services, among others, in accordance with both federal and state laws and regulations. Medicare maintains records for at least seven years.

Organizing wound care records is also essential. Records should be easy to retrieve by date of service and claim, and thus audit ready.

Having “audit-ready” records provides an internal protection mechanism for practices in case of audits (having audit-ready records means you have documentation and/or coding in order so that if an auditor were to come in and review your records, it would be easy for them to verify that everything is accurate). Self-audit’s allow practices to identify and correct documentation and coding errors before a claim becomes denied or subject to a recoupment, which protects both practice revenue and compliance. Practices that have audit-ready records will have fewer recoupments, and therefore less disruption during audits.

Conclusion

Compliance with wound care billing is not about memorizing codes.

Compliance with wound care billing involves developing consistent practices and discipline in documenting wound care, selecting diagnoses, using modifiers, and following up with wound care patients.

Wound care billing will become predictable and not stressful. Clean documentation of wound care supports proper coding.

Proper coding of wound care supports payment for wound care.

Strong internal practices protect wound care practices from audits and potential revenue losses.

That is what sustainable compliance of wound care billing truly represents.