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Documenting Wound Care

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Wound Bed Preparation

  • Cleaning by dabbing wound with saline moistened gauze is standard

Special cases

  • Povidine-Iodine (keep dry gangrene desiccated)
  • Dakin's Solution™ 1/4-strength (foul smelling wounds)

Debridement

  • Autolytic, ie moist and occlusive dressing, isn't explicitly documented (not a form of active debridement)

Chemical or Enzymatic

  • Placed on wound: honey, cadexamer iodine, collagenase
  • Applied to wound on gauze: Dakin's Solution™ (remove dense biolifm or slough; rarely used 2/2 pain)

Mechanical

  • Gauze debridement (rub wound with moistened gauze)
  • High pressure saline or water
  • Wet-to-Dry (rarely used 2/2 pain)

Sharp

Document the procedure, including:

  • Anesthesia
  • Scalpel blade #
  • What was done
  • Excellen hemostasis was noted (or hemostasis was achieved with ...)
  • No immediate complications noted (or discussion of complications)

Dressings

  • Document everything used -- always have at least two layers, but usually three

Primary: directly on top of wound

Commonly used examples include

  • Hydrogels
  • Hydrocolloids
  • Alginatrs
  • Hydrofibers
  • Foams and hydropolimers
  • Gauze
  • Barrier creams on periwound

Secondary: adjacent to primary

Commonly used examples incude

  • Gauze
  • Foam
  • Woven abdominal pads
  • Transparent film (secondary or tertiary)
  • Paper tape (usually tertiary)
  • Cloth tape (usually tertiary)

Tertiary: anchoring or adhesive

Commonly used examples include

  • Transparent film
  • Paper tape
  • Cloth tape

Special cases

Examples include

  • Positioning and protective surfaces
  • DME such as wound-vac
  • Ostomy bag for drainage

Billing Considerations

Include intrinsic and extrinsic wound risk factors and discussion/mitigation.

Make sure to document:

  • Wound stage and size
  • Wound bed preparation
  • Methods of debridement

Selected CPT codes

97597 and 97598 for active wound management

  • Debridement of nonviable tissue from epidermis, dermis, or superficial layer of deeper wounds
  • Includes high-pressure irrigation, mechanical, chemical/enzymatic, and sharp debridement
  • 97597 for first 20cm²
  • 97598 for larger wounds
  • Codes are for wounds in aggregate, not per wound

15002-15005 if debridement in preparation for negative pressure wound therapy for primary closure.