Skin Substitute Documentation

Carriers have been increasing the pre and post claim review for wound graft products being used in the office. Bolster your documentation with these tips:

Pretreatment

Must include the duration of the ulcer by number of weeks notating its exact location on the body.  Describe adequate treatment of the underlying disease process contributing to the ulcer along with the diagnosis of the patient.  Include conservative treatment attempts that have failed.  

Treatment

  • Document the size of the ulcer including width, length or circumference and depth in sq cm.  This should be done immediately prior to the application of the skin substitute. 

  • Document if this is the initial or e-application of the skin substitute.  If a re-application document that applications have been successful (decrease in size or depth, increase in granulation tissue etc)

  • Document all conservate measures accompanying the treatment such as dressing changes. 

  • Document how the wound site was prepared and how the skin substitute was fixated on the wound

  • Document clinical observation and/or clinical judgement necessary to switch skin substitutes

  • Document any product wastage with the following:

  • Date and time

  • Location of ulcer

  • Approximate amount of product unit used

  • Approximate amount of product unit discarded

  • Reason for wastage

  • Manufacture’s serial/lot/batch number

Coding Notes 

  • Make sure to use the appropriate Code for the graft product is used. 

  • Make sure to bill the appropriate application code based on size and location of application.  Application codes have add on codes for additional units needed

  • Make sure to include the JW modifier (Skin Substitute no applied to wound, wastage) for any wastage of the product.  This is done by listing the graft code two times.  Once with the used units and a second time with the wastage units and the JW modifier.

NOTE: Always make sure to check with your product representative for the latest updates and requirements. Check your local coverage guidelines for the specific product being used. The above is a guideline and not a guarantee of payment.

David Swierczskin substitution documentation, wound graft products