Creator: Patrick Connole
Wound Care Documentation and Managed Care Denials
Park Place thought leader, R2 – Reimbursement Reimagined, provides the details you need to know on how to handle wound care and managed care denials.
(The following features Park Place thought leader R2 – Reimbursement Reimagined, a division of Zimmet Healthcare Services Group employing more than 300 staff. R2 offers remote MDS and case management solutions for accurate Medicare, Medicaid, and Medicare Advantage reimbursement. Amy Goldsmith, chief operating officer, leads the group.)
The following information is the work of R2’s Katy O’Connor, vice president of case management services, and Michele Stern, director of clinical education and training.
Setting the Stage
Wound care continues to be a recurring area of concern in managed care denials, including for patients with Stage 3 or Stage 4 pressure injuries who require daily wound treatment. Even when a patient has a significant wound and an ongoing treatment plan, there remains a risk that the payer may question whether the patient continues to require skilled services in a skilled nursing facility.
When submitting clinical updates to the insurance company regarding wound care, it is important that the documentation clearly and consistently reflects the patient's current clinical status. This should include, at a minimum:
Wound measurements and changes in wound size
Current wound status and progression
Wound classification/staging
Drainage, including amount and characteristics
Condition of the surrounding skin
Type of wound treatment being provided
Frequency of treatment
Response to treatment and any changes in the treatment plan
Clinical rationale for the continued skilled level of wound care
Facilities should also ensure that the treatment being provided is accurately documented on the Treatment Administration Record (TAR). We are seeing situations where, when treatment changes to products such as Santyl, the payer questions whether the treatment itself constitutes skilled care. It is, therefore, particularly important that the medical record clearly explain why the wound continues to require skilled nursing assessment, intervention, monitoring, and treatment, rather than relying solely on the name of the treatment product.
There have also been instances in which insurance representatives, during peer-to-peer reviews related to denials, have questioned whether the wound is at a severity level that warrants the current treatment plan and have suggested that treatment should be reduced. In these situations, strong clinical documentation from the treating physician and wound care specialists is essential to support the medical necessity of the treatment being provided.
Discharge Planning and Patient/Caregiver Education
When wound care is the primary skilled need and/or the primary barrier preventing a patient from safely discharging from the facility, discharge planning documentation becomes especially important.
The medical record should demonstrate ongoing efforts to determine whether the patient's wound care needs can be safely managed at a lower level of care. Documentation should include attempts to educate and train:
The patient
Family members or caregivers
Community caregivers or other available supports
Appropriate community resources
When clinically and cognitively appropriate, facilities should also document attempts to determine whether the patient can participate in or independently manage aspects of their wound care. This may include documentation from occupational therapy or other disciplines regarding the patient's ability to physically access the wound, follow the treatment process, and safely perform or participate in wound care.
The discharge planner should also document outreach to appropriate community resources, which may include:
The patient's primary care provider
Wound care clinics or specialists
Home health/home care services
Other community-based services or supports
Private-pay nursing services, when appropriate, if these services could safely meet the patient's needs at a lower level of care
Documenting Community Resources
It is important to remember that although facility staff may have a strong understanding of what community resources can provide, the insurance company, QIO, or appeal board may not have that same knowledge of the resources available in a particular community or what services are realistically accessible to a specific patient.
Therefore, this information should not be assumed to be common knowledge or left undocumented. The patient's individual medical record should clearly explain what community services were investigated, what services are available, what frequency of visits can realistically be provided, and whether those services are sufficient to meet the patient's specific wound care needs.
This information should be documented in the patient's chart so that it is available to the insurance company during continued-stay reviews and, if necessary, can be included in the record submitted for an appeal.
Collaboration With Wound Care Providers
Facilities should work closely with their wound care physicians and wound care specialists to ensure that the clinical documentation clearly establishes:
The current condition and severity of the patient's wounds.
The treatment being provided and the frequency of treatment.
Why the patient's wound care requires skilled assessment, monitoring, and intervention.
The patient's response to treatment and any changes in condition or treatment plan.
The risks associated with transitioning the patient to a lower level of care before their wound care needs can be safely managed in that setting.
Why the identified community resources may or may not be sufficient to safely meet the patient's current needs.
Ultimately, the medical record should tell the complete clinical story. It should clearly demonstrate not only what wound care is being provided, but also why it remains skilled, why the patient continues to require that level of care, what barriers exist to a safe discharge, and what specific efforts are being made to overcome those barriers.
Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.
