Debridement Services
Insufficient documentation causes most improper payments. Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for debridement services:
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- Missing the initial and updated treatment plan
- Operative or procedure note for the debridement services
Initial and updated treatment plan: The initial treatment plan to include the expected frequency and duration of the skilled treatment and the potential to heal. Continuation of treatment plan with ongoing evidence of the effectiveness of that plan, including diminishing area and depth of the ulceration, resolution of surrounding erythema and /or wound exudates, decreasing symptomatology, and overall assessment of wound status (such as stable, improved, worsening, etc.). Appropriate changes in the ongoing treatment plan to reflect the clinical presentation must be present in the record.
Operative note or procedure note for the debridement service: This note should describe the anatomical location treated, the instruments used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post procedure care and follow-up instructions.