Documentation Tips

Documentation Tip: Wound Care

Documentation Tips: Wound Care

There are 3 key principles of wound care documentation:

  1. Wounds are reported in lengths of repair, NOT in dimensions of the wound.  The repair length involves all angles of repair, including curved edges. Measure the full length of each angle of repair, not the diameter or greatest angle.  There is no substitute for measuring each repair. Nursing or triage only estimates the dimension of the wound, never measures, and notes the diameter, not the angles of repair. Document: “x.x centimeters by repair.”
  2. Anatomic locations must be precise for each repair as CPT codes are different for each classified repair within different levels and body area groupings. Codes are sub-divided into body areas, such as scalp/neck/axillae, external genitalia/trunk/ extremities/hands/feet. Note the location of each wound separately repaired. For example, note scalp vs face, scalp vs. upper neck, face vs lip, wrist vs hand. Each can be different codes.
  3. Layers and complexities of the repair must be documented. There are three levels of CPT code classification based on depth and complexity: Simple, Intermediate, Complex.  

Simple: single layer, no particulate, no contamination.

Intermediate: two layers, or single layer with particulate and/or contamination.

Complex: two layers with particulate and/or contamination or physician’s documentation of what made the repair complex.

Levels of repair are increased in complexity 3 ways:

  • By layer.
  • Removal of particulate or foreign bodies
  • Contamination -wounds requiring extensive cleansing or debridement.

Common techniques supporting the most complex level of repair:

  • Wound edge revision to achieve approximation
  • Undermining to achieve approximation
  • Extensive debridement or removal of necrotic tissue or macerated wound edges
  • Extension of the dissection for exploration

Always document the mechanism of injury (blunt sheer, puncture, etc.) and type of wound (stellate, flap, curved). These support the complexity of repair. Document the depth of wound exploration and structures explored as separate codes might come into play depending on several conditions.

Document the precise areas of debridement noting what is near the repair area and what is outside the area as outside debridement can be reported separately. Debridement in and around the wound repair area contributes to increasing the level of repair.

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