Did the rules change regarding wound care as reasonable and necessary?

The rules did not change, but there has been a recent increase in Pre-Claim Review (PCR) non-affirmations when wound measurements and other clinical documentation is not submitted. In order for the wound care to be considered reasonable and necessary, the Medicare Benefit Policy Manual Chapter 7 – 40.1.2.8 Wound Care states, “the size, depth, nature of drainage (color, odor, consistency, and quantity), and condition and appearance of the skin surrounding the wound must be documented in the clinical findings so that an assessment of the need for skilled nursing care can be made.  This includes whether wound care is performed via dressing changes, NPWT using conventional DME systems or NPWT using a disposable device.  Coverage or denial of skilled nursing visits for wound care may not be based solely on the stage classification of the wound, but rather must be based on all of the documented clinical findings.”

In addition to wound identification, stage, and orders for treatment of the wound, the agency should also include a comprehensive assessment that includes measurements, depth, drainage, and skin surrounding the wound so that medical necessity can be determined and PCR affirmation received for skilled nursing.