Documentation for Negative Pressure Wound Therapy

The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy. 

NPWT is defined as the application of sub-atmospheric pressure to a wound to remove exudate and debris from the wound(s). NPWT is delivered to a qualified wound through an integrated system that includes:

• A suction pump
• A separate exudate collection chamber
• Dressing sets

In these systems, the exudate is completely removed from the wound site to the collection chamber.

The beneficiary’s medical record must include information describing the history, previous treatment regimens (if available), and current wound management billed. The medical record must be available for review upon request.

Documentation must include such elements as:

• Length of sessions of use
• Dressing types
• Frequency of change
• Changes in wound conditions, including precise measurements, quantity of exudates, presence of granulation and necrotic tissue, and concurrent measures being addressed relevant to wound therapy (such as debridement, nutritional concerns, support surfaces in use, positioning, and incontinence control)

Information describing the wound evaluation and treatment, recorded in the beneficiary’s medical record, must indicate regular evaluation and treatment of the beneficiary’s wounds.

• Documentation of quantitative measurements of wound characteristics, including wound length and width (surface area), depth, and the amount of wound exudate (drainage) indicating progress of healing, must be entered at least monthly
• To determine whether equipment and supplies continue to qualify for Medicare coverage,thesupplieroftheNPWT equipment and supplies must obtain an assessment of wound healing progress from the treating clinician, based upon the wound measurement as documented in the beneficiary’s medical record
  • CMS may request the beneficiary’s medical records in order to corroborate that wound healing is/was occurring as represented on the supplier’s claims for reimbursement

When billing for NPWT:

• Include a diagnosis code describing the wound treated on each claim for the equipment and related supplies
• The medical record must include a statement from the treating physician describing the initial condition of the wound, including measurements, and the efforts to address all aspects of wound care
• The medical record must, for each subsequent month, include updated wound measurements and what changes are applied to heal the wound
  • Month-to-month comparisons of wound size must compare like measurements (that is, depth compared to depth or surface area compared to surface area)

If the initiation of NPWT occurs during an inpatient stay, document the initial inpatient date of service to accurately account for the duration of treatment. This date must be available upon request.

For additional coverage guidelines, please see Local Coverage Determination Local Coverage Determination (LCD): Negative Pressure Wound Therapy Pumps (L33821).

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