Case Scenarios: Wound Documentation Mistakes
By Cheryl Carver, LPN, WCC, CWCA, CWCP, DAPWCA, FACCWS, CLTC – Wound Educator
Auditing documentation has always been part of my wound nurse role in some way or another. My first experience with auditing documentation with a fine-tooth comb was while working in the hospital wound center setting as a hyperbaric oxygen technician. Back then, hyperbaric oxygen therapy was more difficult to get reimbursed, and there were a lot of Medicare appeals. I would search through stacks of documentation to find validation for the diagnosis specific to the hyperbaric oxygen therapy indication. I quickly found out how ONE word determined reimbursement, and we are not talking pennies. The documentation is either there or it isn’t. Wound care documentation also requires the same impeccable documentation. Reimbursement is driven by Centers for Medicare & Medicaid Services (CMS) guidelines. We must follow the rules, or we do not get paid.
Partial- versus full-thickness wounds should be a straightforward understanding, right? For some reason it is not. It is one of the most common documentation mistakes or inconsistencies that I observe. Validating wound depth is critical from a documentation standpoint in every sense. Wound care billing and reimbursement of procedures, dressings, and durable medical equipment are essentially determined by wound depth. I have compiled a list of common terms that I see used incorrectly and/or inconsistently.
Common Terminology Mistakes
Below is a brief review of common conditions and those they are often mistaken for; for a full review of these conditions, visit my previous blog, Common Wound Care Documentation Mistakes and How to Avoid Them.
Partial-thickness skin loss involves epidermis, dermis, or both. The ulcer is superficial and manifests clinically as an abrasion, blister, or shallow crater.1
Full-thickness skin loss involves damage to, or necrosis of, subcutaneous tissue that may extend down to and through underlying fascia all the way down to the bone.1
Scabs are PARTIAL-thickness. The term “scab” is used when a crust has formed by coagulation of blood or exudate.
Eschar is FULL-thickness. Eschar is dead tissue found in a full-thickness wound. You may see eschar after a burn injury, gangrenous ulcer, fungal infection, necrotizing fasciitis, spotted fevers, and exposure to cutaneous anthrax.
Moisture-associated skin damage (MASD) is PARTIAL-thickness, with NO granulation, slough, or eschar. MASD is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate, and perspiration. MASD is also referred to as incontinence dermatitis.2
Stage 2 pressure ulcer/injury contains NO granulation.
Now that we've taken a moment to review these conditions and how to tell the difference between them, lets look at some hypothetical case scenarios detailing how some common wounds might be mis-documented.
Scenario #1: You have a patient with a non-blanchable area to the left heel. You describe the injury as an erythematous, pink, and dry area with a measurement of 4×4×0.1cm. The wound has been staged as a pressure injury stage 1.
INCORRECT: The measurable depth indicates tissue loss, along with pink wound tissue, which validates a stage 2 pressure injury = partial-thickness.
Scenario #2: You have a patient with a pressure ulcer/injury to the coccygeal region. You document that the wound is 100% pink granulation. You stage the wound as a stage 2 pressure injury.
INCORRECT: Granulation is not possible in a stage 2 pressure injury. Referring to the wound bed tissue as granulation validates a full-thickness wound. The wound is a stage 3 pressure ulcer/injury = full-thickness.
Scenario #3: You have a patient admitted to your facility with a pressure ulcer/injury to the right heel. It consists of 50% black eschar and 50% yellow slough. You palpate the area and feel comfortable documenting a stage 3 pressure injury. The following week during rounds, you notice a small pinpoint area within the eschar and slough mix you can now probe to bone. The stage is now a 4, showing a decline in wound progress.
INCORRECT: The devitalized tissue percentage validates an unstageable pressure injury. Staging the pressure ulcer/injury as a 3 on admission made it appear the wound had declined. Is it also possible the pinpoint open area was missed on admission? The tissue level of destruction was full-thickness on admission and possibly to bone.
Scenario #4: Documented MASD to the right buttock measures 3×3×0.2cm. The tissue is 20% slough and 80% granulation.
INCORRECT: This area is full-thickness. Any devitalized tissue validates full-thickness tissue level of destruction. The wound must now be staged. It would be a stage 3 pressure injury.
Scenario #5: You have an acquired, unstageable pressure ulcer/injury. Wound tissue type is 100% black eschar. The treatment nurse documented a suspected deep tissue injury (sDTI) dry scabbed area intact, measuring 4×4×UTD (unable to determine).
INCORRECT: The term “scab” is found on a superficial or partial-thickness wound. The pressure ulcer/injury stage is unstageable. This is a discrepancy in documentation.
Scenario #6: A physician has documented, "sharp debridement, removed eschar," when it was actually a scab.
INCORRECT: This is now considered a full-thickness wound, leading to an incorrect billing code. Documentation is critical to ensure accurate reimbursement for the procedures performed.
There is an increase in wound-related lawsuits in every health care setting. Most of these lawsuits are pressure ulcer related: common snags and gaps in documentation, wrong pressure ulcer/injury staging, and implementation of treatment are just a few of the possible causes. Weekly audits of wound care documentation will help minimize discrepancies.
1. Baranowski S, Ayello E, eds. Wound Care Essentials. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
2. Centers for Medicare & Medicaid Services. MDS 3.0 Manual v01 07. US Department of Health and Human Services; 2018. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instr.... Accessed 23 January 2019.
About the Author
Cheryl Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. She currently works as a Clinical Specialist for a leading independent provider of wound care solutions for long term care facilities in the United States, American Medical Technologies a d/b/a of Gordian Medical, Inc. Carver is not only known for her knowledge and expertise, but for enjoying her vocation as much as anyone possibly could. Her strong passion is driven from a life long list of personal experiences as a caregiver. Her mother passed away in in her arms at the young age of 47, due to complications from diabetes, amputation, and pressure ulcers. She now has dedicated her professional career to wound care education in hopes to bolster quality of care and strengthen pressure ulcer prevention. She has received many high reviews from her fellow physician and nurse students from across the country, including but not limited to: plastic surgeons, cardio-thoracic surgeons, general surgeons with wound care experience. Ms. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease specific educational video sessions accessible to employee providers and colleagues.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.