The Core Measurements
Measure the same way every visit so progress can be compared. A common method is head to toe for length and side to side for width, at the longest perpendicular points, with depth taken at the deepest point.
- Length, width and depth in centimeters
- Surface area in square centimeters (length times width)
- Undermining and tunneling with clock-face location
- Measurements before and after debridement when debridement is performed
Describe The Wound Bed
Tissue type supports the depth and medical necessity of debridement. Record the percentage of granulation, slough and eschar, the deepest tissue exposed (subcutaneous, muscle, tendon or bone), drainage amount and type, periwound condition and signs of infection.
Show Progress Over Time
Payers want to see that ongoing treatment is working. A note that compares this visit's measurements to the prior visit, and states whether the wound is improving, static or deteriorating, gives the reviewer what they need. When a wound is not improving, document the change in plan.
How Measurements Drive Codes
- Debridement: units are based on the surface area debrided in 20 sq cm increments
- Skin substitutes: the application code and product units follow the wound area treated
- NPWT: wound measurements support initial and continued coverage
- Compression and offloading: measurements show response to standard care before advanced therapy
Frequently Asked Questions
- Should multiple wounds be measured separately?
- Yes. Measure and document each wound separately, then add areas together only where the code definition calls for a total, as with skin substitute application codes.
- Who can take the measurements?
- Clinical staff can measure under the practice's protocols, but the billing provider's note must include or reference the measurements for the visit being billed.
Billing Support For This Specialty
Physicians Professional Billing Services, Inc. has billed wound care, surgical and procedural specialties since 1998, across every Medicare Part B MAC jurisdiction.
Primary Sources
This page is general information about billing and coverage rules and is not legal, coding or reimbursement advice for a specific claim. Coverage policies change; confirm current requirements with CMS and the applicable Medicare Administrative Contractor.