Documentation requirements
The patient medical record maintained by the health care professional must include the following patient-specific information:
•Physician order for treatment
•Documentation to substantiate standard protocols have been met
•Wound description including specific measurements and condition
•Patient-specific treatment plan
Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.